Of all the counties between Puget Sound and the Great Lakes, just two pop up on a U.S. Centers for Disease Control and Prevention map as among the nation's most at-risk for HIV.

Mineral County, Montana (population 4,200) ranks 161st of 220 in the study. Treasure County, Montana (population 700) is 211th.

If that sounds bizarre, imagine what health officials in Montana thought when they scanned the CDC report when it first came out 18 months ago.

"It's hard for us to understand," said Jim Murphy of the Montana Department of Public Health and Human Services. "I don't think the methodology is working that well."

Murphy is chief of the department's Communicable Disease Control and Prevention Bureau, and he's quite familiar with the two counties in question. Mineral is on the timbered west end of the state with a county seat of Superior. Treasure is in ranching country on the rolling prairie along the Yellowstone River. It's centered in Hysham, midway between Billings and Miles City.

Both are transected by railroads and interstate highways, but as Murphy pointed out, so are many counties in Montana, the Missoulian reported . Those appeared to be the only similarities until the CDC study came along.

Murphy said there's no epidemic in either county, and no more reason to worry about an outbreak of HIV or Hepatitis C than in any other county in Montana, and probably quite a bit less than most.

The CDC launched its study in the wake of a 2015 epidemic of HIV infections in Scott County, Indiana. According to news reports at the time, nearly 200 people became infected in the town of Austin, 80 miles south of Indianapolis, largely from injections with contaminated needles of a powerful oral opioid. Some 85 percent of them also contracted Hepatitis C.

"The CDC looked into what happened and said, 'How can we prevent the next Scott County?' That's what led them to doing the study," Murphy said.

Researchers identified six predictors, using data from 2012, 2013 or 2014. They were: drug overdose deaths, unemployment, per capita income, white non-Hispanic population, sales of prescription opioids, and county population for which local providers have been approved to prescribe buprenorphine.

Buprenorphine is used in treatment of substance use disorder to reduce exposure to injections, explained Jenn Donovan, director of the Mineral County Health Department.

When the study came out in 2016, Murphy consulted Steve Helgerson, the state medical officer at the time and a nationally recognized epidemiologist. He said they asked the CDC for clarification and were pointed to a slide show, along with the study and its appendix that gave more detail on the methodology.

"Even when that was said and done, we said, 'Thank you, but it seems like really a stretch to us,'" Murphy said. "It just doesn't make sense. We watch every place in Montana, try to detect things early. Mineral County has had a real good track record in that regard for a long time."

In an email on Friday, Donovan said the curious study results are on the radar of Mineral County medical and law enforcement officials.

"We have not received any information that would indicate that our risk is increasing at this time, including no cases of acute hepatitis C or HIV in recent years," she said.

Substance abuse and unemployment were two of the top four priorities identified in a Community Health Assessment in Mineral County in 2016, the year the CDC study came out. Donovan said the assessment resulted in a health improvement plan and her department is working on implementing the strategies outlined.
Murphy's bureau is not Montana-centric.

"We work with people in other states," he said. "We know of places in Washington that have issues, the Dakotas that have issues, the Bakken oil fields, the reservations. Why do none of them show up in these models?"

By far the lion's share of counties most at risk are in West Virginia and Kentucky, with only scattered counties in the Southwest and the two in Montana making the map.

"We've had very few questions on it," Murphy said. "I don't think the study has really gotten much traction."

He said the states most affected might use the data for leverage to get money for programs, "but to be honest, given what we know, we're not going to redirect resources to these two counties. We work with all of Montana."

Ours is considered a low-incident state when it comes to communicable diseases, and Montana lags behind the nation in opioid abuse and HIV cases.